Provider Demographics
NPI:1093299646
Name:VIRGO CANION, PAULINE
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:
Last Name:VIRGO CANION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 SW 81ST AVE
Mailing Address - Street 2:STE 303H
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068
Mailing Address - Country:US
Mailing Address - Phone:954-588-3708
Mailing Address - Fax:
Practice Address - Street 1:840 SW 81ST AVE
Practice Address - Street 2:STE 303H
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068
Practice Address - Country:US
Practice Address - Phone:954-588-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN1235271164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse